Health Care Reform: A Catholic View.

Quick - what is the Roman Catholic vision for health-care reform in the United States? Answers to this question solicited from "experts" or laypeople would lack much unanimity or force, for reasons which include conflicting institutional interests and the complexity of subject matter. However, the need for such a vision is acute. At this writing, Congress continues to dissemble on the subject of health-care reform while the momentum of public opinion wanes in the face of policy minutiae and the prospect of new taxes. Myriad activities continue at the state level - scaled-down versions of the federal debate. And the health-care financing and delivery "industry" continues to restructure itself for those fortunate enough to have the admission ticket of health insurance. Meanwhile, the everyday tragedies and miracles of illness and cure, fear and hope, play themselves out for patients and their families.

Philip Keane has jumped in to fill the void of systematic analysis and advocacy with his book Health Care Reform: A Catholic View. Keane is a professor of moral theology at Saint Mary's Seminary and University, of Baltimore, and is a consultant to several Catholic health systems. He takes us on a veritable Cook's tour of Catholic moral theology and social thought, health-care ethics, public-policy analysis, and Christian spirituality. By the conclusion, the reader is left feeling somewhat like a traveler at the end of a long airplane journey: happy to have reached the destination, but not quite sure of the topography covered to get there.

Fortunately, for this reader, the destination is the right one. Keane proposes fifteen "conclusions" for a reformed U.S. health-care system informed by a Catholic vision. Those principles include a single-payer financing system, universal coverage, private delivery systems, an acceptance of death as a part of life, explicit distribution of limited resources (i.e., rationing), and additional attempts to secure access for marginalized members of society.

The essence of the "moral framework" upon which Keane builds rises out of the Catholic notions of community and the moral imperative of distributive justice. Citing Jacques Maritain and more recent work by Charles Curran, Robert Bellah, and others, he attempts to retrieve the notion of the responsible community as the nexus of moral agency and urgency. The ability to provide "similar treatment for similar cases" (a phrase coined by the non-Catholic Catholic moral theologian Gene Outka) becomes the gold standard of distributive justice. Individual rights to liberty (nonintervention from a governing body) and responsibility for self-maintenance are subordinate to our need to care for one another. With such a foundation, Keane accomplishes two important tasks. First, he moves the language of reform away from "the right to health care," which inevitably engenders a policy-oriented calculus over exactly what and how much is covered by this "right." Rather, this view argues, the obligation to provide care equitably to all should drive reform efforts.

Second, reinvigorating the language of community shifts the focus from the personal and the societal obsession to prevent, or at least control, death. With this shift, the objective of health care becomes, as Keane quotes a maxim, "Sometimes to cure, often to relieve, and always to console." The dignity of the individual, for a Christian, springs not from one's autonomy, but one's relations to others and a loving God. Such a faith gives comfort in facing the reality of death and personal limits.

Keane could have mounted a stronger Catholic critique of the cultural factors that drive many of the problems of the current system and the inadequacies of certain reform proposals. Individual greed has corroded much of what passes for medical care - from questionable surgeries to the growth in new technologies and pharmaceuticals. Our society's obeisance to a notion of individual autonomy which trumps all other concerns has blocked discourse and societal consensus about collective obligations and reasoned limits.

There is little, moreover, in Keane that compels the reader toward the Catholic vision. In part this lack of forcefulness is due to some lax writing and inattentive editing. But the book also bears the weight of its considerable ambitions. Notions of the common good and distributive justice are not introduced until two-thirds of the way through the work. By then, we have looked at the U.S. health-care system, proposals to fix it as well as other systems, and worked our way through the theology of the human person, the ethics of dying, and the roots of concepts of community. A discussion of Catholic values in a secular world and of levels of cooperation with evil still lies ahead.

Any attempt to cover a terrain so broad, no matter how systematic in intent, will be idiosyncratic in nature. A more selective focus on the foundations of his reform "conclusions" would have sacrificed Keane's desires for comprehensiveness, but permitted fuller discussion of principles such as distributive justice. His exploration of this question is unfortunately truncated. In addition, elaboration on what makes his foundational concepts distinctively Catholic would be illuminating. Finally, had the author chosen to forgo his systematic approach, he could have introduced more narrative, allowing him to reflect and apply his principles and "conclusions" to specific cases.

Is it necessary to be compelled by moral theological reflection when it comes to health care? In this case, yes. Only a morally forceful argument can bore into what we are truly trying to reform in U.S. health care. Our system of financing and delivering care may only be a symptom of the disease. Although any system that consumes almost 15 percent of every dollar produced and still leaves a quarter of the population without adequate coverage and the rest less healthy on average than the citizens of other industrialized countries is worthy of our attention. Rather, a Catholic vision for health-care reform should attempt to reform the way we look at ourselves - in sickness, in health, in life, and in death. And the vision must be persuasive. A strong Catholic voice is needed to help inform a debate shaped by powerful interests of self-preservation, to give voice to those unable to participate in the community to which, as Keane points out, we all belong.